Financial Responsibility Form

Financial Responsibility

I have requested medical services from Associates in Gastroenterology on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Assignment of Benefits

This agreement is to inform you of your financial obligation to our practice. I hereby authorize payment directly to the provider above for any and all benefits for charges for examination and/or treatment received by me and/or my dependent(s). I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Associates in Gastroenterology for medical services rendered to myself and/or my dependents regardless of my insurance benefits. I understand that I am responsible for any amount not covered by insurance.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Authorization to Release Information

I hereby authorize Associates in Gastroenterology to release medical and other information to my insurance carrier regarding my illness and treatments as may be required to obtain benefits for charges for examination and/or treatment received by me or my dependent(s). I also authorize AIG to release medical and other information as needed to Other HealthCare Providers or Referring Physicians directly associated with my care.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PLEASE BE AWARE THAT EFFECTIVE JANUARY 01/2012, THERE WILL BE A $20.00 CHARGE FOR ANY APPOINTMENTS NOT CANCELLED/RESCHEDULED WITHIN 24 HOURS OF THE APPOINTMENT TIME. THANKS